An evaluation of clinical risk factors for estimating fracture risk in postmenopausal osteoporosis using an electronic medical record database.

SUMMARY: Many of the clinical risk factors used in fracture risk assessment (FRAX) calculator are available in electronic medical record (EMR) databases and are good sources of osteoporosis risk factor information. The EPIC EMR database showed a lower prevalence of FRAX risk factors and, consequently, proportion of patients who would be deemed "high risk." INTRODUCTION: The FRAX tool is underutilized for osteoporosis screening. Many of the clinical risk factors for FRAX may be available in EMR databases and may enable health systems to perform fracture risk assessments. We intended to identify variables in an EMR database for calculating FRAX score in a cohort of postmenopausal women, to estimate absolute fracture risk, and to determine the proportions of women whose absolute fracture risks exceed the National Osteoporosis Foundation (NOF) thresholds. METHODS: Our cohort was selected using an EMR database with demographic, inpatient, outpatient, and clinical information for female patients age≥50 in a family practice, internal medicine, or obstetrics/gynecology clinic in 2007-2008. The latest physician encounter was the index date. Variables, problem and medication lists, diagnosis codes, and histories from the EMR were used to populate the 11 clinical risk factor variables used in the FRAX. These risk factor prevalence and treatment-eligible proportions were compared to those of published epidemiology studies. RESULTS: The study included 345 patients. Mean (SD) 10-year risk for any major fracture was 11.1% (6.8) when bone mineral density (BMD) was used and 11.2% (6.5) when BMI was used. About 10.1% of the cohort exceeded the NOF's 20% major fracture risk threshold and 32.5% exceeded the NOF's 3% hip fracture risk threshold when BMD was used. Overall, the number of treatment-eligible patients was slightly lower when FRAX was calculated using BMD versus BMI (13.6 and 36.8%). CONCLUSION: Our cohort using EMR data most likely underestimated the mean 10-year probability of any major fracture compared to other cohorts in published literature. The difference may be in the nature of EMRs for supporting only passive data collection of risk factor information.

Nosocomial H1N1 infection during 2010-2011 pandemic: a retrospective cohort study from a tertiary referral hospital.

This study aimed to estimate the incidence of hospital transmission of influenza A subtype H1N1 [A(H1N1)], to identify high-risk areas for such transmission and to evaluate common characteristics of affected patients. In this single-centre retrospective cohort study, 10 patients met the criteria for hospital-acquired A(H1N1) infection over a three-month period. All affected patients required an escalation of their care and the mortality rate was 20%. Clinicians should be aware of the risk of nosocomial A(H1N1) infection that exists despite routine infection control measures and should consider additional control measures including vaccination of hospital inpatients and healthcare staff.

A[H1N1] flu and refractory hypoxaemia: is extracorporeal lung support the holy grail?

There is a call for methodologically robust randomised clinical trials in adult extracorporeal membrane oxygenation for its routine implementation for patients with "failing" conventional ventilation. Adherence to lung protective ventilation strategies, along with fluid balance [if required early renal replacement therapy] and inotropes to support the circulation to minimise ventilator-induced lung injury, may mitigate deterioration requiring extracorporeal lung support. Currently there is no convincing evidence to routinely advocate extracorporeal lung support in failed conventional ventilation, and a prospective trial is needed to define standard best practice and to tailor extracorporeal lung support referral criteria in young patient cohort with severe refractory respiratory failure.

Drotrecogin alfa (activated): diffusion from clinical trials to clinical practice.

BACKGROUND AND OBJECTIVE: Although the PROWESS trial demonstrated a mortality benefit, subsequent studies in different patient populations have not reproduced the effect. As a result, concerns have been expressed about the clinical effectiveness of drotrecogin alfa (activated). Therefore the aim of this audit was to review the clinical impact of drotrecogin alfa (activated) when used outside clinical trials. METHODS: A retrospective review of ICU charts and medical records of patients who had received drotrecogin alfa (activated) in the five largest users of drotrecogin alfa (activated) in England. Patients characteristics details at ICU admission and vital status at hospital discharge were recorded. The severity of illness was assessed by the APACHE II score (using first 24 h admission data) and the number of organ dysfunctions. Adverse incidents were recorded and any sequence effect explored. RESULTS: In all, 351 patients received drotrecogin alfa (activated) between December 2002 and November 2005. Of those, 201 (57.2%) were male, and 177 (50.4%) were admitted after recent surgery. The patients' average age was 61.8 yr. The mean admission APACHE II score was 23.3 and the average number of dysfunctional organs on admission was 3.3. The hospital mortality was 46.7% (164 deaths). The expected number of deaths calculated by using the APACHE II risk of death was 173 (49.3%) and by number of sepsis induced organ failures 210 (59.7%). Overall, there were 33 (9.4%) adverse incidents. CONCLUSIONS: Expected mortality derived from both the APACHE II score and organ dysfunctions suggests that drotrecogin alfa (activated) does reduce mortality. Serious adverse incidents occurred in 5.1% patients; however, the direct contributing effect of drotrecogin alfa (activated) cannot be established from this type of audit.

Postoperative changes in prothrombin time following hepatic resection: implications for perioperative analgesia.

Disorders of coagulation may occur after uncomplicated hepatic resection in patients who have normal preoperative coagulation profiles and liver function tests. We present a retrospective study performed in a tertiary care university teaching hospital examining changes in liver function tests and coagulation profiles in patients undergoing hepatic resection. Data were obtained for 124 patients. When compared to the preoperative values, prothrombin times were significantly increased throughout the postoperative period. Prolongation of the prothrombin time was related to both duration of surgery and hepatic resection weight. There was no relationship between prothrombin time and patient age. Disorders of coagulation occur after hepatic resection even in patients who have normal preoperative coagulation and liver function tests. This has implications for anaesthetic practice, particularly when considering the use of an indwelling epidural catheter in patients undergoing hepatic resection.

Guidelines, compliance, and effectiveness: a 12 months' audit in an acute district general healthcare trust on the two week rule for suspected colorectal cancer.

OBJECTIVES: The Department of Health had recently introduced guidelines so that all suspected colorectal cancer patients could be seen by a specialist within two weeks of referral by their general practitioners. The usefulness and practicality of such a decision had been questioned. The aims of this study were to measure the compliance to the guidelines and evaluate the effectiveness of such referrals. METHODS: All patients who were referred to the rapid access colorectal clinic between August 2000 and July 2001 were included. SETTINGS: Darlington Memorial Hospital and Bishop Auckland General Hospital, both under South Durham Health Care Trust, were considered for the study. MEASURES: Date of referral, referring practitioner, time of appointment, reasons for referral, and diagnosis. RESULTS: A total of 239 referrals were made; 96.2% of patients were given appointments within two weeks. Rectal bleed was the commonest (32%) cause for referral. Diverticular disease was the most frequent (29%) condition diagnosed. Altogether 97.4% of referrals were incomplete and 37.6% did not comply with the guidelines. Twenty one colorectal cancers (8.9%) were diagnosed. The early cancer detection rate was 4.6%. CONCLUSIONS: This audit showed that compliance to the guidelines was associated with a higher cancer detection rate. The majority of patients received appointments within two weeks. Contrary to some speculations, the number of referrals was not limitless. However a high number of referrals failed to adhere to the guidelines. The cancer (particularly early cancer) detection rate was disappointingly low. This does not reflect an efficient system of referral and potential benefits to patients remain questionable.

Seasonal variation in admission rates to intensive care units.

Intensive care physicians perceive that there is seasonal variation in the number of admissions to critical care services. There is, however, little published evidence to support this belief. Data were therefore collected from five adjacent critical care units in the eastern region over a period of 8 years, in order to quantify any seasonal variation that may exist. Data on 16 355 critically ill patients were obtained between 1992 and 2000. Analysis showed clear winter peaks; December had a 30% higher admission rate than the quietest month, February. There was a small, but increasing, summer peak. The admission rate also exhibits an increasing linear trend, equivalent to a 6.6% annual increase in admissions per critical care bed. We conclude that there is significant seasonal variation in critical care activity, and that this is important to consider when planning services.

Analysis of the promoter region of human cartilage oligomeric matrix protein (COMP).

Cartilage oligomeric matrix protein (COMP) is an extracellular matrix protein expressed in cartilage, ligament, and tendon. The importance of COMP in the matrix of these cells is underscored by the discovery that mutations in COMP cause the skeletal dysplasias, pseudoachondroplasia (PSACH) and multiple epiphyseal dysplasia (EDM1). Here, we present the first report on the analysis of the human COMP promoter region in cartilage, ligament, and tendon cells. A 1.7-kb region of the COMP promoter has been cloned and sequenced and no TATA or CAAT boxes were found. Primer extension identified multiple transcription start sites. All four transcription start sites were utilized in chondrocytes with only three of them utilized in tendon and ligament cells. Differential regulation was observed for different parts of this 1.7-kb region with the 370-bp proximal region conveying the strongest promoter activity. The highest activity was observed in tendon and ligament. Finally, we provide evidence that the DNA binding protein SP1 plays a role in the regulation of COMP expression. These results indicate that COMP expression within these cells is regulated in a unique manner that differs from the expression of other extracellular matrix genes.

Reducing the demand for admission to intensive care after major abdominal surgery by a change in anaesthetic practice and the use of remifentanil.

We have used a remifentanil-based anaesthetic for patients undergoing major abdominal surgery who would normally have gone to the intensive care unit in this hospital. Avoiding intensive care unit admission was considered an advantage as a shortage of intensive care unit beds was leading to the cancellation of operations. We first used remifentanil as part of a safety and efficacy study. The aim was to see if the rapid and complete awakening obtained when using this drug would allow us to avoid the need for admission to an intensive care unit and use a high dependency unit instead. This was shown to be practicable. In comparison with a group of patients matched retrospectively for the type of operation before remifentanil was used there was a reduction in the length of time (mean+/- SD) patients' lungs were ventilated (612+/-417 vs. 9.9+/-28.9 min P< 0.0001). There was no saving in cost ( pound808.71+/- pound187.06 vs. pound795.27+/- pound253.49). When remifentanil was used routinely (after the safety and efficacy study), there were significant reductions in the time to tracheal extubation (612+/-417 vs. 4+/-10 min P < 0.0001) and costs (808.71I vs. 392.10 I P < 0.0001) compared with other patients in whom it was not used. Patients waiting for a liver transplant were also being cancelled when a donor organ became available because of the shortage of intensive care unit beds. Based on our other experience with remifentanil, we used a similar anaesthetic technique for these patients. It proved possible to extubate the trachea in 12 of 15 patients at the end of the operation. No patient needed re-intubation. The need for intensive care and therefore cancellation of surgery was reduced. In contrast, only one patient's trachea was extubated immediately after surgery in the group of patients anaesthetized before the introduction of remifentanil. A remifentanil-based technique in combination with a change in organization has therefore enabled us to avoid admission to the intensive care unit for these patients.

Life-threatening airway obstruction caused by a retropharyngeal haematoma.

We present the case of a 68-year-old woman who had a large cervicomediastinal haematoma that caused life-threatening airway obstruction. Retropharyngeal haematoma may occur in any age group and following a variety of causes. Retropharyngeal haematomas must be considered as a cause of airway obstruction following common injuries such as blunt cervical trauma or internal jugular vein cannulation. A high index of suspicion and early lateral neck X-ray is essential for safe management of this rare but potentially life-threatening injury.

A comparison of hospital and critical-care activity.

When compared with changes in hospital activity, corresponding fluctuations in critical-care activity are not clear. Therefore, trends in hospital activity were compared with those of the critical-care services and simple patient demographic details. The results suggest that while the size of hospitals remained static, hospital admissions and outpatient attendances increased by 5% each year. During the same period, the number of critical-care beds increased by 21.4%. Despite this increase in capacity, the activity of the critical-care services continued to increase by a similar 5% per annum, indicating a huge surge in critical-care workload. The results indicate that the increase in the rate of activity in hospitals and critical-care services is similar but the workload of the critical-care services is increasing much faster. This suggests that the demand for critical care may be generated from within hospitals.